Case Reports
A Case of Swallow Syncope
Peter K. Moore, MD Jenny K. Lee, MD Joel A. Garcia, MD Mori J. Krantz, MD
Swallow syncope, also called deglutition syncope, is a rare disorder triggered by oral intake. Patients often have underlying esophageal or structural heart disease. In some cases, the condition can be treated conservatively by eliminating predisposing factors. We describe the case of a 65-year-old woman without cardiovascular or esophageal disease who presented after a motor vehicle accident that was attributed to syncope while driving and eating. In the hospital, the patient suddenly lost consciousness while eating solid food; complete heart block without ventricular escape was documented on continuous electrocardiographic monitoring. A dual-chamber permanent pacemaker was placed and completely resolved the symptoms. This case illustrates a high-risk manifestation of swallow syncope: asystole resulting from an exaggerated vago–glossopharyngeal reflex. (Tex Heart Inst J 2013;40(5):606-7)
S
wallow syncope is an infrequently reported event. Lost consciousness is temporally related to the ingestion of fluids, solids, or both. The condition is often associated with underlying esophageal disorders and can occur in the presence of cardiac disease.1 We describe a case of swallow syncope in a woman who had no evident cardiac or esophageal disease.
Case Report
Key words: Deglutition/ physiology; deglutition disorders; eating/physiology; heart block/complications/ diagnosis/physiopathology; syncope, vasovagal/ diagnosis/etiology/therapy; treatment outcome From: Cardiology Division, Department of Medicine, Denver Health Medical Center, Denver, Colorado 80204 Dr. Lee is now at Pueblo Cardiology Associates, PC; Pueblo, Colorado. Address for reprints: Mori J. Krantz, MD, MC 0960, Denver Health Medical Center, 777 Bannock St., Denver, CO 80204 E-mail: [email protected] © 2013 by the Texas Heart ® Institute, Houston
606
Swallow Syncope
A 65-year-old woman was admitted after a motor vehicle accident. She described experiencing syncope while simultaneously driving and eating. She reported a history of intermittent lightheadedness that was temporally related to solid-food intake. On admission, the patient displayed a heart rate and blood pressure within normal limits and without orthostatic changes. The results of cardiovascular examination were normal. A 12-lead electrocardiogram showed sinus rhythm without conduction abnormalities. On the first day of hospitalization, the patient lost consciousness while eating a solid dinner. Telemetry revealed complete atrioventricular (AV) block without ventricular escape rhythm (Fig. 1). An echocardiogram showed normal right and left ventricular chamber dimensions and systolic function. No valvular lesions, wall-motion abnormalities, or ventricular hypertrophy were noted. No structural pathologic condition was detected on esophagogastroduodenoscopy. The patient was diagnosed with swallow syncope, and after a dual-chamber permanent pacemaker was implanted, her symptoms resolved and did not recur.
Discussion Swallow syncope is a relatively rare condition that was first reported in 1793.2 It has also been called deglutition syncope and has been lightheartedly referred to as “vasobagel syncope.”3 In this phenomenon, loss of consciousness occurs upon the ingestion of solid substances, liquids, or both.1 The resultant cardiac rhythm disturbances include sinus bradycardia, sinus arrest, complete heart block, and asystole. Hypotension without a corresponding disturbance in cardiac rhythm can also occur.4 Swallow syncope is often associated with underlying esophageal pathologic conditions, such as esophageal spasm, stricture, diverticulum, cancer, achalasia, and hiatal hernia. Cardiac pathologic conditions are also associated with swallow syncope.1 Various mechanisms could be responsible for swallow syncope. Artificial synapses between the glossopharyngeal and vagus nerves in some patients might lead to an exaggerated vagal discharge at the heart upon swallowing.1 Alternatively, a reflex arc Volume 40, Number 5, 2013
Fig. 1 Telemetry strip shows a syncopal episode as the patient ate dinner. The vertical dotted line marks the start of food intake. Arrowheads show P waves.
might exist between the afferent sensory limb of the vagus nerve from the esophagus and the parasympathetic fibers that innervate the heart. With such a reflex arc, distention of the esophagus by food could result in inappropriate vagal activation. Regardless of the exact mechanism, excessive parasympathetic output to the heart seems to be central to this phenomenon, because atropine effectively prevents bradyarrhythmias and syncope in most patients.1,4 As described in the present case, the diagnosis of swallow syncope relies upon establishing a clear temporal relationship between oral intake and syncope. Esophageal pathologic conditions must be excluded, and an evaluation of cardiac structure and function should
Texas Heart Institute Journal
be performed.4 If a specific food trigger is identified, avoidance of that trigger might mitigate the symptoms.3 Medications that cause bradycardia and AV block should be discontinued. Anticholinergic therapy can be attempted; however, these drugs can be poorly tolerated. When an underlying esophageal pathologic condition is identified, it is reasonable to attempt to treat it. When syncope is mediated through marked bradycardia, AV block, or asystole, permanent pacemaker implantation should be considered as an effective treatment approach.1,4 However, pacemakers are not effective if the cause of syncope is unrelated to a cardiac rhythm disturbance, so documentation of bradyarrhythmia must precede permanent pacemaker implantation.4
References 1. Omi W, Murata Y, Yaegashi T, Inomata J, Fujioka M, Muramoto S. Swallow syncope, a case report and review of the literature. Cardiology 2006;105(2):75-9. 2. Lea CE. Dr. Thomas Spens: the f irst describer of the Stokes-Adams syndrome. Proc R Soc Med 1914;7(Sect Hist Med):243-6. Available from: http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC2003557/ [cited 2013 Oct 15]. 3. Farb A, Valenti SA. Swallow syncope. Md Med J 1999;48(4): 151-4. 4. Mitra S, Ludka T, Rezkalla SH, Sharma PP, Luo J. Swallow syncope: a case report and review of the literature. Clin Med Res 2011;9(3-4):125-9.
Swallow Syncope
607
A Case of Swallow Syncope
Peter K. Moore, MD Jenny K. Lee, MD Joel A. Garcia, MD Mori J. Krantz, MD
Swallow syncope, also called deglutition syncope, is a rare disorder triggered by oral intake. Patients often have underlying esophageal or structural heart disease. In some cases, the condition can be treated conservatively by eliminating predisposing factors. We describe the case of a 65-year-old woman without cardiovascular or esophageal disease who presented after a motor vehicle accident that was attributed to syncope while driving and eating. In the hospital, the patient suddenly lost consciousness while eating solid food; complete heart block without ventricular escape was documented on continuous electrocardiographic monitoring. A dual-chamber permanent pacemaker was placed and completely resolved the symptoms. This case illustrates a high-risk manifestation of swallow syncope: asystole resulting from an exaggerated vago–glossopharyngeal reflex. (Tex Heart Inst J 2013;40(5):606-7)
S
wallow syncope is an infrequently reported event. Lost consciousness is temporally related to the ingestion of fluids, solids, or both. The condition is often associated with underlying esophageal disorders and can occur in the presence of cardiac disease.1 We describe a case of swallow syncope in a woman who had no evident cardiac or esophageal disease.
Case Report
Key words: Deglutition/ physiology; deglutition disorders; eating/physiology; heart block/complications/ diagnosis/physiopathology; syncope, vasovagal/ diagnosis/etiology/therapy; treatment outcome From: Cardiology Division, Department of Medicine, Denver Health Medical Center, Denver, Colorado 80204 Dr. Lee is now at Pueblo Cardiology Associates, PC; Pueblo, Colorado. Address for reprints: Mori J. Krantz, MD, MC 0960, Denver Health Medical Center, 777 Bannock St., Denver, CO 80204 E-mail: [email protected] © 2013 by the Texas Heart ® Institute, Houston
606
Swallow Syncope
A 65-year-old woman was admitted after a motor vehicle accident. She described experiencing syncope while simultaneously driving and eating. She reported a history of intermittent lightheadedness that was temporally related to solid-food intake. On admission, the patient displayed a heart rate and blood pressure within normal limits and without orthostatic changes. The results of cardiovascular examination were normal. A 12-lead electrocardiogram showed sinus rhythm without conduction abnormalities. On the first day of hospitalization, the patient lost consciousness while eating a solid dinner. Telemetry revealed complete atrioventricular (AV) block without ventricular escape rhythm (Fig. 1). An echocardiogram showed normal right and left ventricular chamber dimensions and systolic function. No valvular lesions, wall-motion abnormalities, or ventricular hypertrophy were noted. No structural pathologic condition was detected on esophagogastroduodenoscopy. The patient was diagnosed with swallow syncope, and after a dual-chamber permanent pacemaker was implanted, her symptoms resolved and did not recur.
Discussion Swallow syncope is a relatively rare condition that was first reported in 1793.2 It has also been called deglutition syncope and has been lightheartedly referred to as “vasobagel syncope.”3 In this phenomenon, loss of consciousness occurs upon the ingestion of solid substances, liquids, or both.1 The resultant cardiac rhythm disturbances include sinus bradycardia, sinus arrest, complete heart block, and asystole. Hypotension without a corresponding disturbance in cardiac rhythm can also occur.4 Swallow syncope is often associated with underlying esophageal pathologic conditions, such as esophageal spasm, stricture, diverticulum, cancer, achalasia, and hiatal hernia. Cardiac pathologic conditions are also associated with swallow syncope.1 Various mechanisms could be responsible for swallow syncope. Artificial synapses between the glossopharyngeal and vagus nerves in some patients might lead to an exaggerated vagal discharge at the heart upon swallowing.1 Alternatively, a reflex arc Volume 40, Number 5, 2013
Fig. 1 Telemetry strip shows a syncopal episode as the patient ate dinner. The vertical dotted line marks the start of food intake. Arrowheads show P waves.
might exist between the afferent sensory limb of the vagus nerve from the esophagus and the parasympathetic fibers that innervate the heart. With such a reflex arc, distention of the esophagus by food could result in inappropriate vagal activation. Regardless of the exact mechanism, excessive parasympathetic output to the heart seems to be central to this phenomenon, because atropine effectively prevents bradyarrhythmias and syncope in most patients.1,4 As described in the present case, the diagnosis of swallow syncope relies upon establishing a clear temporal relationship between oral intake and syncope. Esophageal pathologic conditions must be excluded, and an evaluation of cardiac structure and function should
Texas Heart Institute Journal
be performed.4 If a specific food trigger is identified, avoidance of that trigger might mitigate the symptoms.3 Medications that cause bradycardia and AV block should be discontinued. Anticholinergic therapy can be attempted; however, these drugs can be poorly tolerated. When an underlying esophageal pathologic condition is identified, it is reasonable to attempt to treat it. When syncope is mediated through marked bradycardia, AV block, or asystole, permanent pacemaker implantation should be considered as an effective treatment approach.1,4 However, pacemakers are not effective if the cause of syncope is unrelated to a cardiac rhythm disturbance, so documentation of bradyarrhythmia must precede permanent pacemaker implantation.4
References 1. Omi W, Murata Y, Yaegashi T, Inomata J, Fujioka M, Muramoto S. Swallow syncope, a case report and review of the literature. Cardiology 2006;105(2):75-9. 2. Lea CE. Dr. Thomas Spens: the f irst describer of the Stokes-Adams syndrome. Proc R Soc Med 1914;7(Sect Hist Med):243-6. Available from: http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC2003557/ [cited 2013 Oct 15]. 3. Farb A, Valenti SA. Swallow syncope. Md Med J 1999;48(4): 151-4. 4. Mitra S, Ludka T, Rezkalla SH, Sharma PP, Luo J. Swallow syncope: a case report and review of the literature. Clin Med Res 2011;9(3-4):125-9.
Swallow Syncope
607
